Reports from Ecuador

Independent Project: Recycling Update

Since we last talked about Amanda’s efforts to start recycling programs at Fundación Futuro clinics, we’ve seen the project get off the ground with a great response!  Bins for glass, plastic and paper are now installed at the clinics in Planchaloma and Yatzaputzan, as well as the women´s cooperative in Yatzaputzan.  The bins in Planchaloma are currently overflowing and ready for transport next time we return to Quito.  Amanda found a company that is willing to buy recyclable items, so we are hoping to turn this environmentally-inspired project into a money-maker for the clinic.

Independent Project: Library

While Amanda’s project has been taking hold, I have started my own independent project.  Since coming to Ecuador I have been catching up on my ever-growing reading list.  One book that I particularly enjoyed was The Boy Who Harnessed the Wind, the account of a boy from rural Malawi who improved living conditions for his family and village by building a windmill–a project inspired and guided by books from his local library. The description of his village reminded me in many ways of Planchaloma–many people without proper healthcare, electricity, education, water supply, etc.  However, the people here do not have access to a library of bookstore.  While there is an internet cafe, its users are limited to children playing games after school.  With this in mind, we decided to launch a modest book collection at the clinic where patients can read where they wait for the doctor and check out books to take home.  Right now we have a modest selection of 82 books, ranging from science textbooks to children’s stories, but Lorena, the nurse at the clinic, had the same idea as Amanda and: the clinic has volunteered to use the funds produced by the recycling program to buy additional books for the library.

While most people were initially hesitant to use the library, once we introduced people the system and assured them that it was a free service, we have gotten a positive response.  We hope that word spreads around the community so that people are aware of this resource.

Lab-in-a-Backpack Progress

The clinic in Planchaloma recieved some exciting news this week with regard to the Lab-in-a-backpack: they have contracted a lab tech who will visit the clinic every Saturday to use the materials in the pack!  Amanda and I demonstrated the pack to her today, and she was very impressed with what all it contained.  We are relieved to know that the backpack will continue to be used once we go home next week.

We also had the opportunity to demonstrate Sally to the lab tech and her son, who is a doctor.  He was especially excited about the design since he himself had constructed a manual centrifuge using a bicycle in med school.

View From Our Window

So this isn’t exactly project related, but one of my favorite blogs has a “View From Your Window” series, and I thought I would post some pictures of the spectacular panoramic we are lucky enough to wake up to everyday (well, as long as it’s not too cloudy).

To the West: Las Ilinizas, which we affectionately refer to as the Lord of the Rings mountains

To the East: Cotopaxi, the volcano that lends its name to the province

In our spare time, we have tried to take in the amazing countryside, and one afternoon we hiked up a mountain (it’s really more of a hill, but at this altitude it felt like a mountain).

As long as we’re off topic, Amanda and I would like to take a moment to mention the weather in Planchaloma, which we have decided is more fickle than Houston’s.  Though today was the hottest day of our internship, it hailed.  Five minutes later, the sun came out and we were treated to an incredible rainbow over the cascading hills.

Ecuador Culture

Since arriving in Ecuador, and particularly Planchaloma, we have had the privilege of experiencing the rich, indigenous culture here.  We have gone to festivals, watched dance performances, and observed high school graduations.  It’s a great way to take a break from work and get to know the way of life here a little bit better.

Cuy, AKA guinea pig, one of Ecuador's delicacies. Everyone here thinks it's hilarious that Americans keep these animals as pets!

Throughout our visits to Yatzaputzan and Planchaloma, we have made slow but steady progress on developing both the Community Health Outreach and OB/GYN backpacks.

CHO Pack

We quickly learned that the CHO pack, originally designed for community outreach workers in Malawi, would be used by the promotores de salud at Fundación Futuro’s health centers in Ecuador.  We have talked extensively with Marta from Planchaloma and Angel and Evita from Yatzaputzan about ways to improve the backpacks, and have learned that while they have the medical training to use all the supplies currently provided, their focus is more on health education in the communities surrounding the clinic.  As such, we have designed a series of educational flipbooks (hygiene, oral health, nutrition, family planning, vaccinations and recycling) to put in the backpack that they can use with individual patients or during larger brigades.  We’ve also included a dry erase board and markers that they can use to improvise additional lessons.  They also requested additional medical supplies, including an adult scale, masks, suture kits, a WHO Colour Scale, a sharps container and a pediatric blood pressure cuff, some of which we have been able to find in Quito. We also need to find new containers for urine samples, since they only use sterile cups here.  We hope that once we finalize these changes we will be able to take the CHO pack on another brigade to assess the impact of these improvements.

Reviewing our new educational materials with Angel and Evita before printing the final copies.

OB/GYN Pack

This issue of sterility has posed several major challenges for the implementation of the OB/GYN backpack.  Patients here will not use speculums that have been used on other women, even if they’ve been properly sterilized.  Instead, they use disposable speculums.  Furthermore, the obstetricians use individually-packaged spatulas and brushes in order to keep them sterile, whereas those in the backpack are contained in one large bag.  Until these changes are made, we are unable to use the backpack in the field.  In the meantime, we have translated the backpack’s educational materials into Spanish, and have discussed the frequency of use of each of the backpack’s procedures.  While pap smears and birth control counseling are common, the doctors at the clinic do not perform biopsies, but rather refer patients to a larger hospital.

We are eager to finalize these modifications so that we can bring the new and improved versions into the field for use with patients.

Having returned to Quito with María Alicia on Thursday, we made out second visit to Yatzaputzan early Friday morning.  This time, rather than working with the women’s cooperative, we were able to meet with the staff at the clinic in order to get feedback on the technologies we brought with us.

Though Amanda’s AccuDose syringe clips have not arrived yet (fingers crossed that they’ll be ready soon!) she had the opportunity to discuss the design with the “promotores de salud,” Fundación Futuro’s version of community health outreach workers.  Overall, the staff seemed very excited about the idea and certainly thought that the clips would help prevent overdosing.  They use 5 mL syringes and doses range from 1.5 mL to 3.5 mL, so we are hoping that the clips that are currently being made at Rice will be compatible.

We also reviewed the CHO pack with the promotores, who gave us great feedback on the design.  They told us that they do use everything currently in the pack, but they also requested an adult scale, thermometer (ours broke) and a pediatric blood pressure cuff (which we were unable to find in time for our trip).  Also, one of the main responsibilities of the promotores is health education in the community, so they liked our idea of including educational materials such as flipbooks and diagrams related to hygiene, family planning, vaccinations and nutrition in the backpack, something we’ll be working on developing this week.

Finally, we demonstrated Sally, the salad spinner centrifuge, to the promotores.  Again, they were disappointed that it required 10 minutes of spinning, but expressed that it would be useful in their clinic, which occasionally loses power.  Their apparent favorite aspect of the design was the reader cards.  Anemic hematocrit levels depend on age and gender (i.e. hematocrit of 38 is healthy for women but not men), so Lauren and I designed a set of reader cards (seen above) to accompany Sally that indicate anemia levels directly on the chart, making it eaiser to diagnose the condition.  With these reader cards, they would be able to test for anemia without the lab technician who visits only once a week.  While we’re working in Quito this week, we hope to make a similar set of reader cards for ZIPocrit so that they can screen for anemia more frequently.

On Wednesday of last week we spent the day at a school in Yugische Alto–about a 30 minute drive from Plancha–doing our recycling and hand-washing charlita with the kids as well holding a mini-medical brigade.

The doctors in Planchaloma were hoping to use Sally to screen the kids for anemia, but since it’s not ready for use on patients yet, we suggested using the tools in their lab-in-a-backpack instead.  Currently, the health center in Planchaloma lacks a lab technician, so they haven’t been able to use the lab-in-a-backpack as planned, but Amanda and I realized that there are many technologies in the backpack that with a quick training, the doctors and nurses could easily use themselves.  One such device is the ZIPocrit (the electrical centrifuge used to find hematocrit and diagnose anemia) that we used many times to evaluate Sally in the lab.

We arrived at the school, and the kids were really excited to see us once Nicolas, the clinic administrator, reassured them that they would not be getting any shots (little did they know that we would be pricking their fingers ).  They responded really well to the talk, and it was great to do it in front of the doctors and nurses from the clinic so that we can get their feedback on ways to improve the lesson.  After the educational portion of the visit, we went ahead with the plan to screen the kids for anemia using the lab-in-a-backpack.  While the process initially seemed straightforward enough, we ran into some problems.

We quickly realized that one finger prick on the small children did not produce enough blood to adequately fill the capillary tubes currently in the lab-in-a-backpack.  We went ahead and centrifuged the blood we were able to collect, hoping to use the tape measure to determine packed cell volume, but after five minutes in the ZIPocrit, the blood had not separated, and instead had clotted.  We believe that this can be easily fixed by using smaller, heparinized capillary tubes like the ones we brought to use with Sally.  That way, we wouldn’t need so much blood and the blood would not clot.

Since we didn’t have the alternate capillary tubes with us, we went ahead and used the WHO Color Scale with the kids, which was much easier to use.   It requires much less blood and is ready for interpretation in 30 seconds.  We discussed this semester in our independent research class that the flaw in the color scale is that its results are very subjective, which we did find to be true, but it seemed to be the best option given the constraints of the environment.

One big take-away from the trip was that contrary to their preconceptions, doctors, nurses and community health outreach workers can perform many of the tests in the lab-in-a-backpack without the help of a lab-technician.  Because lab technicians are unavailable to many clinics, we believe that with a quick training, these medical professionals can diagnose diseases that they currently do not even screen for.  This was a theme that would also present itself in Yatzaputzan…

We arrived in Planchaloma on Thursday with María Alicia, Richard and Lorena.  Richard is a Belgian/German/Ecuadorian chemical engineer who is collaborating with Fundación Futuro in an agriculture project.  The aim of the project is to introduce canola as a crop here and eventually build a refinery so that people here can sell all-natural canola oil to restaurants in Quito.  It was so interesting to learn more about this out-of-the-box way to grow the economy in Planchaloma.  Lorena is a local sociology student who is also working with a foundation in downtown Quito.  She is shadowing María Alicia in order to learn more about how microfinance works so that her organization can implement it with the urban poor.  Having spent extended time in the US, she has been especially great in helping us navigate some of the cultural differences we have already encountered here in Planchaloma.

After a quick introduction to the health center here and a trip to Latacunga for “chugchucaras” (a typical local meal of pork, plantains, potatoes and empanadas) and groceries, we finally settled in at our new home.  We are staying in a room in the corner of the clinic with bunkbeds, a kitchen, and showers (which as of this morning provide hot water!).

The community is absolutely lovely.  The town itself (no more than 30 small buildings) is nestled in the mountains with Cotopaxi (the volcano that lends its name to the province) directly out our window.  Walking down the cobblestone street in front of the clinic, we immediately find freely-roaming pigs, cows, donkeys and sheep.  Everyone here has been so welcoming and generous.  The experience is more than worth the lack of amenities like consistent power, warm showers and familiar food.

We spent Friday getting to know the clinics staff–Nicolas, the system administrator; Marta, the health promoter; Lorena, the nurse; as well as the general medicine doctor, OBGYN specialist and dentist.  After observing the clinic’s routine for a while, we rode with the regional president (who was elected to preside over the communities in a 2-hour drive radius) to a local school to teach about hand washing.  We got to meet the children there as well as their parents, who came for the Día de los Niños festival.  They were so welcoming–especially the little kids who each shook our hands one by one.

Saturday is the clinic’s busiest day, but we managed to find time to demonstrate the backpacks to the staff there.  They seemed enthusiastic about the contents, but we are slightly concerned that they don’t need the backpacks so much as they need the supplies since Marta told us that they’ve been doing fewer brigades in recent years.  The real test will come on Wednesday when we go on our first medical brigade!

We spent this morning (a half-day for the clinic) demonstrating Sally to Nicolas, who really liked the concept of the centrifuge, but was disappointed that it wasn’t ready to test on patients.  We hope that somewhere down the line we will have Sally at that stage of development!

We’ll spend the rest of the week in two more schools and then on the medical brigade before returning to Quito for the weekend.

Sally–the salad spinner centrifuge Lauren, Kelly, Nazima and I have spent the past year developing–made her Ecuador debut today!  Amanda and I drew six samples of blood and demonstrated the centrifugation process to María Alicia, Marisol, Daniel (a volunteer at the office) and a member of the custodial staff.  We centrifuged all six at the same time (meaning that one of the five comb segments was holding two blood samples).  The staff at Fundacíon Futuro seemed excited about the process for collecting  blood samples and loading them into the centrifuge, but was ostensibly disappointed that it would take 10 minutes of spinning for the blood to separate, a known disadvantage of the device.  However, everyone was surprised at how quickly the time passed, and so excited for the results!  Everyone took turns using the adapted reader cards, and they appreciated that we had marked the anemic zones directly on the reader card.  While we did not run control samples in the Zipocrit, the benchtop model widely used in the US, Sally seemed to work beautifully!  There was one exception: one blood sample did not entirely separate, leaving a pinkish region occupying about one-fifth of the blood volume.  We observed severalpossible reasons for this anomoly.  First, when we drew this sample, we were having difficulty collecting enough blood, creating three large air bubbles.  Of the other samples, there was a small bubble in about half of them, but not as big or as many as in this unsuccessful sample.  On that note, it was exciting to see that for all samples with bubbles, Sally worked well enough to force out the air, something that we had struggled with in lab.  Second, this blood sample was the one sample that was not centered within a comb; it was at the extreme end of one of the combs, although I did make sure that it was still lined up with the middle correctly.  The other possibility is that we drew this blood sample last, meaning that it had the least amount of time to separate naturally via gravity.  Hopefully we will be able to determine what exactly caused the problem when we take it to the communities.  Overall everyone at Fundación Futuro seemed very, very excited about Sally, so we are eager to see what the health promoters in Plancha Loma think about the design.

FYI: Given the unreliable internet situation, we have decided to split up blogging responsibilities so that our entries do not overlap.  To read about our experience in its entirety, visit ecuador.blogs.rice.edu.  Thanks for reading!

Thursday featured a day trip to Guayaquil, the same coast city where our incoming flight from Houston landed to refuel before eventually arriving in Quito. After a half-hour flight from Quito, we spent the morning touring the city with Marisol, who is originally from Guayaquil, as our guide. We took a taxi to the base of a huge hill, and then climbed the 500 steps to the top in order to get an aerial view of the city.

After climbing back down the hill, we spent the rest of the morning walking along the boardwalk area, which is home to monuments, statues, beautiful flowers and trees, street vendors and lots and lots of people. The boardwalk let us to the bahía, a huge tent marketplace where vendors are eager to sell everything from artisan craft and jeans to watches and toys. We then took a taxi (which sounded like it was going to fall apart any minute) to the main plaza, where we were greeted by hundreds of freely roaming iguanas! We could not believe how many there were, and how calm they were!

We then continued to a nice hotel for typical Ecuadorian lunch: pork, a llapingacho (kind of like a mashed potato and cheese pancake), fried plantains and salad. After lunch we finally made our way to the neighborhood 30 minutes outside of the city where Fundación Futuro has a clinic. The community was obviously an extremely poor area, but the clinic itself was very nice. María Alicia and Marisol were there to administer an exam to the health promoters, and Amanda and I were the pretend patients. This was a great way for us to help them out and also see first-hand how their clinic system operates. When patients arrive, health promoters introduce them to the clinic. They emphasize that while the foundation supports them, it truly is the community’s clinic. Patients pay up to 50 cents for the visit, which does not cover the actual costs of their medical care, but does give value to the services that they receive. Health promoters than take their weight, height, blood pressure and temperature, and direct them to see the doctor in general medicine, dentistry, psychiatry or gynecology depending on their needs. It was such a privilege to see the foundation’s work up close and meet the people on the front lines of health care in this developing country. As we learn more about the foundation’s clinics, it becomes easier to envision the role of the technologies we brought from Rice. When we go to Planchaloma next week we hope to begin demonstrating the suite of backpacks along with Sally and the AccuDose. Until then, it’s been a great experience getting to know the people involved with Fundación Futuro and learn about the heroic work they do throughout the country.

FYI: Given the unreliable internet situation, we have decided to split up blogging responsibilities so that our entries do not overlap.  To read about our experience in its entirety, visit ecuador.blogs.rice.edu.  Thanks for reading!

After the weekend’s introduction to Quito, Amanda and I spent Tuesday and Wednesday working at Fundación Futuro’s central office. When we arrived on Tuesday morning, the amazing María Alicia explained to us the foundation’s mission and history, which would be essential for us to understand in order to best contribute to their work.

The foundation was started by Grupo Futuro—a collection of five companies in Ecuador including Tecniseguros, which shares its office with the foundation. The foundation originated out of the conviction that business has an obligation to not only producing quality goods and services, but also to give back to the community in order to protect the environment and improve the conditions of marginalized populations.

Today, the foundation supports medical clinics in six different rural, indigenous communities and two neighborhoods in Guayaquil, Ecuador’s biggest city. Each clinic is run by a network of doctors, nurses and health promoters who work together to provide general medicine, dental, gynecology, psychiatry and pharmaceutical services to patients at a minimal cost.  The foundation also supports educational and microfinance projects.  María Alicia emphasized to us that the foundation exists to support the needs and wishes of the community rather than impose a paternalistic agenda, and as such collaborates with community leaders in order to develop requested services and does charge a nominal fee for medical care.

Tuesday afternoon and Wednesday we worked on a promotional campaign for hand-washing to be used by the health promoters. Many people in the communities the foundation works with don’t have public health programs in place that teach such important hygiene habits. Luckily, I had worked on a hygiene education project for my BIOE 260 class, and had these resources available. So far, we´ve developed a series of activities for children that convey the importance of washing your hands as well as promotional posters for the clinics and other public places.

As we were designing these materials, it came to our attention that the lack of hand-washing is only part of the problem—none of the indigenous communities have access to potable water. I mentioned to María Alicia the SODIS (the protocol that disinfects water after 6 hours of sun exposure), and she suggested that we do a trial in Planchaloma, where they’re currently conduction a water quality study.

Once we make the final revisions to the hygiene materials, we’ll begin a similar project for recycling. Because many indigenous communities on recently began to use plastic goods, they have not yet implemented a recycling program, something the foundation would like to work with them to change.

So far the work has been really interesting and we’ve felt useful.  Hopefully this continues as we begin to visit the communities and work directly with doctors and patients!